Gender Bias and Discriminationin Nursing Education

Can We Change It?

Ann Strong Anthony, MSN, RN

Gender bias in nursing education impedes recruitment andretention of males into the profession. Nurse educators who areunaware of men’s historical contributions to the profession mayunknowingly perpetuate gender bias.The author describes howtraditional stereotypes can be challenged and teaching/learningstrategies can be customized to gender-driven learning styles.

Contemporary nursing literature,both research-based and popularpress, is replete with examples of gen-der bias and its impact on males seek-ing to pursue a nursing career.1- 4 Theoutcomes of gender bias are harmfulto the profession and create a cyclethat perpetuates bias and limits therole of male nurses. This cycle resultsin different learning experiences formales and females as nursing stu-dents,3,4 limits recruitment and reten-tion of males into the profession5 andperpetuates traditional male/femalestereotypes that make the professionirrelevant to the diverse populationthat the profession claims to representand serve.6-9

Nursing: A FeminineProfession?

The feminine roots of nursing werestrengthened 150 years ago as theprofession began to organize aroundprinciples espoused by FlorenceNightingale and concurrently, becameaccepted as a legitimate option for un-married Victorian women who soughtemployment. Prior to Ms Nightingale,nursing was considered low statuswork. Nurses originated from 3sources: women who were primarilyhome-based and cared for kin andneighbors, members of religious or-ders who had taken vows to care andserve, and rough, uneducated lay at-tendants who chose nursing as a lastresort for their subsistence.10,11

Nightingale insisted that womenmust control their own work in nurs-ing12,13 and proposed training pro-grams for women seeking to becomenurses. The Nightingale TrainingSchool for Nursing opened in 1860

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and served as a model for otherschools both in England and theUnited States.14,15 Nightingale’s em-phasis on hygiene and environment,careful data collection and analysis,and her standards for character andperformance expectations amongnurses increased the value of nursesand nursing’s contribution in society’sperception. Popular support ofNightingale’s achievements created alegitimate foundation for the develop-ment of nursing as a respectable ca-reer option for unmarried women andreinforced the view that nursing waswomen’s work.15,16

European religious sisterhoodswere another model for the nursingtraining programs that developed fol-lowing Nightingale’s reforms. Thismodel extended the increasingly pop-ular view of nursing as women’swork. The nurse role was viewed assubservient to the physician who di-rected the care and administered thehospital. The training environmentmimicked the cloistered atmosphereof a religious sisterhood and was de-signed to preserve virtue and protectyoung women from outside contami-nation. This environment served toexclude males from training as nursesand isolated female nurses.10,15,17,18

The vision of the kindly, caringfemale evolved into the stereotype of“nurse” following the advent of orga-nized nursing training. The nurse iconsoon represented an individual whowas “subordinate, nurturing, domes-tic, humble, and self-sacrificing.”8(p6)

Males who are perceived to be strong,aggressive, and dominant ceased tobe seen as having a legitimate role innursing.15 Meadus describes this ashaving the effect of ostracizing malesfrom nursing.8

Nursing: An HistoricalCareer for Males?

Meadus further proposes that the con-tributions of males to nursing havebeen “forgotten” as nursing evolvedinto a stereotyped female role.8 Yet,males have historically assumed care-giver roles throughout history datingas far back as biblical times.

Caregiving in ancient civilizationswas often closely tied to religiousworship and a role assumed by priestsand their assistants. There was littledifferentiation between the role of thephysician and the nurse. The care-givers described are typically male,often priests or commissioned bypriests, and provided care through in-

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Author Affiliation: Associate Dean, Nurs-ing Division, Tulsa Community College,Tulsa, Okla.

Corresponding Author: Ms Strong An-thony, Nursing, Tulsa Community College,909 S Boston, Tulsa, OK 74119 (aanthony@tulsacc.edu).

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cantations, administration of herbalremedies, and offered care and com-fort to their patients. Donahue sug-gests that much of their actions wouldbe considered nursing by today’s stan-dards.14

The Mosaic Laws of the Bibleprovide an example of the relation-ship between religious worship andhealth practices. The purpose of Mo-saic Laws was health promotion andpreservation of the chosen people.These laws prescribed behaviors andactions specific to hygiene, sanitation,and food preparation. Hebrew priestscould be described as parish nurseswho promoted both the spiritual andphysical health of their religious com-munity (Deuteronomy 14:1-21; Leviti-cus chs 11-15).14

In addition to Moses and Judeo-Christian culture, males assumed rolesas caregivers in ancient societies in-cluding Persia and Babylon. In Indiaaround 275 BC public hospitals weredeveloped and nursing was differenti-ated from medical care. Male nursesprovided care in these hospitals whilephysicians treated wounds and per-formed surgery. Females in India,however, did not work outside thehome and were not perceived asnurses.14 In early Christian Greece andRome orders of monks known asParabolani were organized to providecare for the ill.19 The role of the dea-con and deaconess described in theNew Testament included ministeringto the needy, including the ill and in-jured, and could be fulfilled by eithera male or female (1 Timothy 3:11, Ro-mans 16:1-2).20

During the Middle Ages, the roleof the caregiver continued to be opento both males and females. Religiousorders that accepted a primary mis-sion of caregiving were formed.Among these orders were the Augus-tinian brothers and sisters whofounded the Hotel Dieu in Paris. Typ-ically, care was segregated with thebrothers caring for male patients andthe sisters caring for females.14

Military nursing orders developedduring the Crusades to provide care toknights and other pilgrims making thejourney to the Holy Land. The KnightsHospitallers of St. John of Jerusalemand the Teutonic Knights were com-posed of men who nursed the sickand injured when not in battle. There

continues to be a strong relationship be-tween the call for men to care for sol-diers and military campaigns.10,14,16,19

The military nursing orders in theMiddle Ages were predominantlycomposed of male nurses and empha-sized caregiving as a service based onthe altruistic ideals of love, humility,and caring and brought increased sta-tus to nursing as a profession. Thetenets of caring for our own were in-corporated into craftsmen’s guildsduring the Middle Ages. As a part oftheir mission to support the workerswithin the craft, guilds provided theinfrastructure and resources to carefor elderly and injured workmen.14,21

Men have often taken active rolesin caring for the wounded in wars.During the American Civil War, one ofthe better known male caregivers wasWalt Whitman. Although hired as aclerk, Whitman found his calling inministering to wounded soldiers.Whitman’s poems and other writingsfrom this era describe his holistic ap-proach which, despite his lack of for-mal nurse training, included attentionto nutrition, pain control, cleanliness,and hygiene.22

Segregation of genders in caresettings resulted in the need for for-mal training for men to care for malepatients even in the post-Nightingaleera. Deplorable conditions in theSouth African mines in 1914 led to theappointment of male health workersto “regulate, observe, report on and toa limited extent, [and] treat woundedand sick men.”17(p7) These workerswere typically African natives whowere trained to be medical attendants.The training was aligned with the ex-isting regulations for nursing. Thesemen were not permitted to apply fornursing certification until the latterhalf of the 20th century.17

Nurse training programs for menwere formed in the late 19th centuryto meet the needs in gender-segre-gated care facilities, especially in themental health arena. In the UnitedStates, New York’s Bellevue was thefirst hospital to provide a separatetraining course for men. Mental healthhospitals also established nursing pro-grams for men. Graduates of theseprograms were expected to meet thesame requirements to be an RN aswomen graduates. Males in these pro-grams frequently experienced a cur-

riculum that was limited to those areasin which male intervention was val-ued such as cardiac, pulmonary, uro-logic care, management of fractures,and control of psychiatric patients.19

Those men who sought to expandtheir learning experiences to incorpo-rate the full range of nursing practiceincluding obstetrics and maternal-child nursing were perceived as beingperverts and threatened with expul-sion from programs.23,24

Despite the limited recognitiongiven to their role and the overem-phasis on women’s contributions tonursing, historically, males have par-ticipated in caregiving and been de-scribed as nurses. Since World War II,men have been commissioned as offi-cers and nurses in all of the Americanmilitary services. Although males rep-resent only between 6% and 8% of thetotal nursing population, they com-prise nearly 30% of military nurses.25

The proportion of men in first-respon-der roles and specialty practice suchas emergency and critical care hasgrown at a faster rate than the totalnursing population in recent years.26

Failure to recognize the contribu-tion of men to the profession leavesthe male population with little infor-mation about their gender’s historicalroles as caregivers.10 This lack ofknowledge may contribute to a sensethat men are breaking new ground bychoosing nursing as a career option inthe 21st century. As males enter nurs-ing programs, they may feel more likea pioneer starting a treacherous jour-ney into previously unexplored fron-tiers rather than following a well-blazed trail. Such negative per-ceptions limit nursing’s ability to re-cruit from the nearly 50% of the pop-ulation that is not female.

Gender Bias in NursingHistory Texts

Nursing texts that refer to the histori-cal foundations of nursing practiceoften provide only limited informationabout men’s contributions to the pro-fession while emphasizing women’scontributions.11,27,28 These incompletepresentations of nursing history con-tribute to the perception that nursingis a female profession in which therole of men is limited. Villanueve con-cludes that “the language and history

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of nursing have sexualized nursingpractice by labeling it as women’swork.”23(p213)

As the feminist movement hasgrown, nursing has begun to be per-ceived not only as a woman’s profes-sion, but also as an oppressed profes-sion. In her classic 1976 work, JoannAshley documented how the tradi-tional training programs developed onthe Nightingale model led to the sub-ordination of the nursing professionin healthcare settings.18

More recently, Group and Roberts12

focused on nursing as a profession op-pressed by the male medical monop-oly. They postulate that educated andeffective nurses have been a competi-tive threat to physicians and the orga-nized power structure within health-care throughout history. Examples ofpersecution of women healers by thechurch or medical leaders are pre-sented to illustrate their case.12

The authors provide a detailedhistory of women’s contribution tohealing and caring throughout theages and contrast this caring focuswith the rise of the medical professionbased on university education withlimited clinical practice. Unfortu-nately, by limiting their focus to gen-der politics between female nursesand male physicians, the role of menin nursing is downplayed in a waythat leaves little room for male voicesto contribute to current discourseabout nursing’s role in the future ofhealthcare.

Group and Roberts12 refer to thedemise of the National Joint PracticeCommission as an example of howthe predominantly male medical pro-fession has sought to systematicallysubordinate the nursing profession.The commission was an initiative be-tween organized nursing and medi-cine in the 80s that unsuccessfullysought to find common ground be-tween the 2 professions. Dr EdwardHalloran, a nursing representative tothe commission, described the focuson gender and economic issues by thefemale nursing members of the com-mission as the barrier that preventedtrue dialogue about the unique contri-butions of the 2 professions to achiev-ing health outcomes.12(pp294-5) Whenanalyzing Halloran’s comments,Group and Roberts seem to belittle hisopinion as originating from “a male

nurse...[who] deemphasized genderand stressed instead the functions in-volved in care.”12(p259) This quoteseems to epitomize the argument thata man cannot understand whatwomen experience. This sort of atti-tude further limits our ability to estab-lish a dialogue between genders in amanner that will promote understand-ing and support diversity within theprofession.

Nursing texts that understatemales’ contributions as nurses andemphasize the growing view of thenursing as an oppressed professionlimited by gender politics essentiallymarginalize men in the profession andperpetuate the female stereotype ofnursing. If cultural knowledge is theprocess of seeking and obtaining asound educational foundation aboutdiverse cultures, the fact that nursingtexts do not fully portray men’s con-tributions to the profession limitsnursing educators’ ability to provideculturally competent educationalpractices to support males seeking ca-reers in nursing.29

MacIntosh26 postulates that whenthe nursing profession perpetuates thefeminine stereotype and uncriticallyuses a feminine language and valuesystem, individuals who do not fit thatstereotype are “at risk for being op-pressed and silenced” by those whodo fit the image.(p176) This outcomecan be avoided by developing a bet-ter understanding of gender issues inthe traditional education environment,nursing, medicine, and healthcare cul-tures, and the learner’s experiencesand gender identity. Nurse educatorswho are aware of gender issues andavoid gender bias in texts and histori-cal frameworks of practice can betterfacilitate learning and prepare nurses,both male and female, to move froma sense of being oppressed to beingempowered professionals.

Nursing Education: The Male Experience

In addition to texts that provide an in-complete picture of nursing’s history,traditional nursing programs continueto perpetuate gender bias and to dis-criminate against men in nursing. Agrowing body of qualitative researchinto male lived experiences in nursingprograms demonstrates that the male

experience in nursing school is per-ceived to be different from that experi-enced by female students. Unfortu-nately, few studies present comparisonsbetween the lived experiences of menand women in nursing programs. With-out these comparisons, it is difficult tofully evaluate the context in whichmales describe their experiences. How-ever, these studies demonstrate thatmales do perceive their experiences innursing education as being differentand that little has been done to changethese perceptions.

Typically nursing programs treatstudents who are male similarly to stu-dents who are female. While this pro-motes equality of treatment, it doesnot necessarily take into considerationunique learning needs and differingcommunication styles of men. Kelly etal found that male students were sur-prised by the academic load in nurs-ing, experienced role strain related toloss of their role as the primary in-come provider, and experienced feel-ings of isolation and loneliness whilein nursing school.4 These students re-ported fears of being perceived as un-manly for having chosen nursing. Inaddition, the male students perceivedthat their female peers and instructorsseemed to have different expectationsfor male nursing student performancein the clinical setting. The male stu-dents felt that they were expected tobe assertive and to assume leadershiproles when working in groups withpeers. The male students in this studyalso reported having to “take on extrajobs” such as assisting with heavy lift-ing and transporting patients.

In another study that exploredmale students’ perceptions of their nurs-ing education experience, similar con-cerns were expressed.30 The men inthis study described themselves as a vis-ible minority and perceived that theirperformance is, therefore, more closelyscrutinized than their female peers.These students described themselves asbeing “under a microscope.”30(p.34)

Learning to care professionally isa core behavior in nursing that maybe experienced differently by malenursing students. In western societies,males are socialized to limit visible ex-pressions of emotions while the op-posite behavior is expected of fe-males. Female nurses are likely todisplay caring behaviors through

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touch and open expression of emo-tion. This demonstrative caring behav-ior is seen as “natural” for femalenursing students to learn, but it isviewed as unnatural for male stu-dents. Paterson et al found that malenursing students perceived a need todevelop their own way of express-ing/demonstrating caring that sup-ported their self-view as men.30 Thesestudents expressed concern that whiletheir caring was based on establishingconnectedness with their patients, itmight not be valued by female nurseeducators who expected caring be-haviors to be outwardly sensitive anddemonstrative.

In addition to experiencing differ-ent performance and behavioral ex-pectations, male students reported asense of having different learning ex-periences, especially in clinical set-tings. Learning health assessment,providing care to clients of both gen-ders, and participating in postpartumcare were identified by several au-thors as being different for male nurs-ing students.3,4,30-32

Male students who had recentlycompleted their maternal-child healthclinical rotation reported fear of beingperceived from a sexual rather thanprofessional perspective by femalepatients. Being “extra-professional” intheir demeanor and approach was acommonly cited coping mechanism.3

Lavendero reports that developing asense of how to present oneself pro-fessionally is essential for male stu-dents to avoid having their genderperceived as a distraction.1 This pro-fessional presence is required to pro-vide care in a variety of settings in-cluding women’s health services.

Social isolation and lack of rolemodels are common themes reportedby male students in nursing programs.Males in these programs note thatthey do not naturally socialize withtheir female student counterparts. Thepercentage of male students who aremarried and have family commitmentsas well as perceptions that others mayhave of their sexual identity are fac-tors that may lead to social isolation.32

Another issue raised in severalstudies is the importance of male rolemodels during the students’ educa-tional process. One male stated “malenursing students don’t have many malerole models among teachers. That’s re-

ally important because you have tohave that gender connectivity.”2(p28)

Male faculty represent a low proportionof the total faculty in nursing programsdespite efforts to recruit and retainmore male nursing students. In 2002, asurvey of nursing education programsin 16 states demonstrated misalignmentbetween the percentage of male stu-dents enrolled and the percentage ofmale faculty. Although 11% of the en-rolled student body was male, only 5%of the faculty were male. Of the report-ing schools, less than 19% had in-creased the gender distribution of fac-ulty over the past 5 years.33

While nursing programs are tar-geting males, little is changing withinthe programs to promote retention ofthese recruits.31 The major themes ofthe male experience in nursing schoolinclude perception of threats to sexualidentity, role strain, social isolation,different performance expectations,and sense of having different learningexperiences. These issues have beenreported in multiple sources overmany years and are related to theimage of nursing as a feminine pro-fession.4,34

Strategies to Reduce NursingEducation Gender Bias

As nursing seeks to become more rep-resentative of the population it serves,

nursing education must be able to re-cruit and retain a diverse cohort ofstudents including males. Nursing fac-ulty members need to become sensi-tive to those subtle incidents of gen-der bias that may have a significantimpact on student learning and suc-cess. To minimize gender bias, nurs-ing faculty must become aware ofmen’s contributions to the profes-sion—not only in recent years whenthe focus on male recruitment hasincreased, but the historical rolesmale nurses have taken. Nursing fac-ulty also need to evaluate texts forperpetuation of the feminine stereo-type of nursing and that highlightgender politics as the basis fornurses’ oppression or lack of statusin healthcare.

Finally, nursing faculty need toidentify and eliminate practices thatcreate a sense of difference in howmale and female students experiencethe program. Figure 1, Gender Appro-priate Practices for Nurse Educators,presents strategies that nurse educa-tors can incorporate to maximizelearning opportunities for both maleand female nursing students.

Summary

Gender bias does exist in nursing ed-ucation and can lead to discriminationagainst male students. Nursing educa-

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• Use formative evaluation during clinical rotations to evaluate the quality ofclinical learning and identify perceived barriers to learning.

• When possible, match male nursing students with male academic advisors.• Establish mentoring programs in which male nursing students can interact

professionally with practicing male nurses.• Minimize isolation of male students in clinical rotations by providing clinical

experiences for males in which they are grouped with other male nursingstudents.

• Throughout the curriculum, integrate references about the contributions tonursing and professional practice by males.

• Evaluate test items to avoid unnecessary gender distinctions related tocaring and caregiving.

• Seek nursing texts that positively portray males as nurses; avoid gender-biased texts that reference nurses as women.

• When possible, customize teaching strategies to match learning styles byoffering opportunities for self-directed learning, computer-assisted learning,and other strategies that promote active learning.

• Use cooperative learning activities to increase collaboration and todecrease competition.

Figure 1. Gender appropriate practices for nurse educators.

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tors may not intend to demonstratebias or to act in a discriminatory man-ner. Ignorance of the historical rolethat males have played as caregivers,acceptance of the feminine stereotypeof nursing, gender bias in nursing his-tory texts, overemphasis on nursing asan oppressed profession, and prac-tices that create different learning ex-periences for male and female stu-dents are the basis for unintentionalbias and discrimination.

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